Basic Information
| Provider Information | |||||||||
| NPI: | 1386070894 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KIM | ||||||||
| FirstName: | CHUNG | ||||||||
| MiddleName: | WON | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11190 WARNER AVE STE 300 | ||||||||
| Address2: | |||||||||
| City: | FOUNTAIN VALLEY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 927084045 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 11190 WARNER AVE STE 300 | ||||||||
| Address2: | |||||||||
| City: | FOUNTAIN VALLEY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 927084045 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7148936008 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/17/2013 | ||||||||
| LastUpdateDate: | 07/17/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 21840 | CA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363LA2100X | 21840 | CA | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Acute Care |
No ID Information.